Provider Demographics
NPI:1194929067
Name:WOOD, MARY JOAN (MHS CCC SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JOAN
Last Name:WOOD
Suffix:
Gender:F
Credentials:MHS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 115
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:MO
Mailing Address - Zip Code:65239-0115
Mailing Address - Country:US
Mailing Address - Phone:660-295-4278
Mailing Address - Fax:
Practice Address - Street 1:501 WEST SHORE DRIVE
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:MO
Practice Address - Zip Code:65239
Practice Address - Country:US
Practice Address - Phone:660-295-4278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO115037235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO855258703Medicaid
MO464741008Medicaid
MO464741024Medicaid
MO464741016Medicaid